Socio-economic and demographic determinants of tobacco use in Kenya: findings from the Kenya Demographic and Health Survey 2014

Introduction Every year, more than 6,000 Kenyans die of tobacco related diseases (79 men and 37 women die per week), while more than 220,000 children and more than 2,737,000 adults continue to use tobacco each day. Some suggest that these numbers will rise without concerted efforts to strengthen the implementation of tobacco control measures. To date, there remains much to be learned about what contributes to tobacco consumption in Kenya. This study analyses the socio-economic and demographic determinants of tobacco use in Kenya. Methods To analyze the determinants of tobacco use in Kenya, this study uses the 2014 Kenya Demographic and Health Survey. A logistic regression is used to estimate the probability of an individual smoking, given a set of socio-economic and demographic characteristics. Results Results suggest that the overall smoking and smokeless prevalence rate is 17.3% and 3.10% respectively among men. Women have low rates with smoking and smokeless prevalence standing at 0.18% and 0.93% respectively. However, for both genders, tobacco use is influenced by age, marital status, residence, region, educational status and gender. Conclusion Socio-economic, demographic and geographic disparities on tobacco use should be explored in order to ensure prudent allocation of resources used for tobacco control initiatives. Allocation of resources for tobacco control including monitoring advertisements, sales to underage persons and general distribution of human resource for tobacco control should be based on socio-economic and demographic dynamics.


Introduction
Tobacco use is one of the leading causes of death globally, accounting directly for nearly 6 million deaths annually and approximately 4% of total disease worldwide-behind only childhood underweight, unsafe sex and blood pressure [1]. It is expected that by 2030, tobacco use will produce the highest burden of premature mortality and disability in the world compared to other health risk factors with low and medium income countries being more affected by this burden than high income countries [2]. In Kenya, every year, more than 6,000 people die of tobacco related diseases, while more than 220,000 children and more than 2,737,000 adults continue to use tobacco each day. Additionally, 79 men and 37 women are killed each week as a result of tobacco use [3]. Kenya actively participated in the negotiations of the WHO Framework Convention on Tobacco Control (FCTC) and in 2004 was one of the first wave of countries to ratify the treaty. In addition, the Tobacco Control Act (TCA) was enacted in 2007 to control the production, manufacture, sale, labelling, advertising, promotion and sponsorship of tobacco products and the regulations gazette in 2016 [4][5][6].
Despite the passage of the TCA 2007 which institutes a ban on cigarette advertisement, sale of cigarettes to minors, sale of single stick cigarettes to consumers and smoking in public areas, data suggests that tobacco use is still high when compared to countries in sub-Saharan Africa. GATS data shows that the prevalence rate of smoking in Kenya is high when compared to other African countries with 11.6% or 2.5 million Kenyan adults consuming tobacco (19.1% men and 4.5% female). In Uganda the prevalence rate stands at 7.9% (11.6% men and 4.6% women); Nigeria at 5.6% (10.0% men and 1.0% women); Senegal at 6.0% (11.0% men and 1.2% women) while Cameroun is at 8.9% (13.9% men and 4.3% women) [7][8][9]. The economic costs and the implications for the health and quality of life from these relatively high levels of consumption in Kenya are great. The need to strengthen tobacco control efforts is further punctuated by the ever-present tobacco industry who is actively seeking to expand its market in Kenya [10,11]. In Kenya, while a national plan has been developed to combat tobacco use e.g. Tobacco Control Action Plan 2010-2015 and the Strategy for Prevention and Control of NCDs 2015-2020, little is known about the demographic characteristics of tobacco consumption and the variables associated with this consumption. This data is needed to accurately track consumption trends, including the impact of tobacco control policies over time and the role of socioeconomic characteristics in influencing people to consume tobacco products.
Understanding these determinants and factors is also important when coming up with intervention policies as scarce resources will be prudently directed towards the factor and socio-economic dynamic with the highest influence. The objective of this paper is to identify and analyze the socio-economic and demographic determinants of tobacco use in Kenya. Tobacco use prevalence: Among the male DHS respondents, 17.30% and 3.10% indicated using smoking and smokeless tobacco respectively (table 1). The prevalence is low among male respondents between ages 15-19 years, with smoking at 2.06% and smokeless at 0.39%. However the prevalence increases as the age bracket changes peaking with those at the age 45-49 years having the highest prevalence at 28.49%. Similarly, smokeless tobacco use increases with age peaking at 5.79% with those between 35-39 years before reduction of between 4.34% and 4.36% for those between 40-49 years and increasing again to 5.71% for those between 50-54 years. Smoking prevalence is seen to be similar for both urban and rural areas with urban areas having a slightly higher rate. Similar trend is seen for smokeless tobacco use among males but with rural areas being slightly higher. Tobacco use among men also varies with educational levels. Those with no education have a higher consumption of smokeless tobacco at 20.10% and this reduces as educational level increase with those having higher education having a prevalence of 0.56%. However, while the smoking prevalence is 15.67% for those with no education, the number increases to 21.76% for those with primary schooling but the prevalence rate drops as educational levels increase reaching 10.48% for those with higher education qualification. Male smoking prevalence is highest among those who are employed in the agricultural sector and service-manual sectors at 21.52% and 21.62% respectively while those in the non-manual sector have a prevalence rate of 12.76%. Male respondents that are unemployed have the lowest prevalence rate of 2.31%. Similar trend is seen for smokeless tobacco with the unemployed having the lowest rate of 0.83% while those in the agricultural and service-manual the highest at between 4.63% and 3.92% respectively. Results suggest that smoking prevalence among men increases significantly with age with men ≥20 years five to thirteen times likely to smoke. For example, men between 20 years and 30 years are five to nine times more likely to smoke while those between 30 and 54 years are twelve to thirteen times likely to smoke tobacco.

Methods
On the other hand, prevalence of Men using smokeless is likely to be between five and eight times for men ≥20 years. The Male smoking prevalence between the singles and those who lived together with a partner was likely to be the same. However, married men were 15% less likely to smoke while those who are divorced, separated or widowed were 1.4 times likely to smoke tobacco.
Results however also suggest that while married men's prevalence of smokeless tobacco was low, those whose who lived with a partner were twice as likely to use smokeless tobacco while those who are divorced, separated or widowed were 1.5 times as likely to use smokeless tobacco. Despite the low rates of smoking and smokeless tobacco use, smoking patterns among females was robust. Women in the age bracket of 20-30 are as much as two times more likely to use smokeless tobacco compared to those 15-19 years while those aged 45-49 years are 3.8 times more likely to smoke compared to those aged 15-19 years. Smoking prevalence also increases with age albeit with mixed results. We see that there is a probability that those aged between 20 to 30 years are between two and four times likely to smoke cigarettes. This number reduces for those aged between 30 and 40 years because the probability of women using cigarettes in this age is 92% more likely to use cigarettes but for those above 40 years, there is a huge surge with women up to 4 times likely to use cigarettes. Married women are the least likely to use both smoking and smokeless tobacco products. Results suggest that those who lived together with a partner were 46% more likely to use smoking tobacco and 48% more likely to use smokeless tobacco. However, when the women got married, the probability of smoking reduces by 41% while that of using smokeless tobacco reduces by 26%.
Due to the relatively lower prevalence rates and wider socio-

Discussion
Results highlight differences and patterns of tobacco use in Kenya.
Smoking has a bigger magnitude among men than smokeless tobacco. However, both are consistent as the prevalence is considerably more among older men than the younger ones. The same can be said among women though smokeless tobacco use is higher. This is expected because of the addictive nature of tobacco consistent with other findings that conclude that soon after initiation, nicotine addiction makes withdrawal unpleasant and many find themselves regular smokers [14,15]. Low prevalence among young adults (≤22 years) could also suggest that ban on advertising and increase in tobacco taxes have been effective tools. Older generations have more spending power and have relatively higher prevalence rate because at their time of youth, advertising and branding was allowed making initiation easier. Research shows that initiation usually begins in teenage with tobacco advertisement and other marketing strategies of the industry such as branding leading to tobacco initiation and sustained use among the teenagers [16][17][18]. It is also important to note that consumption among women remains low across all regions in Kenya. This is a positive starting point for tobacco control proponents. However, this pattern should not be taken for granted nor ignored. Research has found that the tobacco industry actively targets women as part of their effort to expand their market. Strategies have included manufacturing products specifically targeting women [19,20], and marketing tobacco consumption as a symbol of empowerment [21]. In other words, tobacco control efforts must continue to focus on this demographic to prevent a surge consumption. Consumption patterns in the survey follow a logical pattern because educational levels and public awareness are impactful in reducing tobacco use on the more literate population. The results are consistent with a country at the early stages of the tobacco epidemic [22]. High smokeless tobacco use in rural areas with lower incomes is also expected because smokeless tobacco is cheaper and people likely to consume it. Also, the likelihood of having poor and uneducated is higher in rural areas [23,24]. Further, the findings suggest that perhaps smokers who are poor and uneducated live in rural areas.

Conclusion
Results suggest that tobacco use in Kenya varies socioeconomic, demographic and geographic factors. County governments should ensure that there is a budget component for tobacco control including monitoring of media advertisements and tobacco sales, with allocation dependent on the prevalence rates of tobacco use in the county as opposed to the current format where counties allocate on adhoc basis. There is also need for the national government, through the ministry of education to ensure that the education policy incorporates tobacco control and non-communicable disease. This is particularly important because the Ministry of Education is currently in the process of reviewing the educational curricular and system meaning that such a move could be effective because

Competing interests
The authors declare no competing interests.